Plymouth Home Based Intermediate Care (HBIC) - Personal Care, Rehabilitation & Reablement (Managed Service)

NHS Devon is seeking to procure a managed Pathway 1 home-based intermediate care support service for Plymouth - to fully manage provision to support circa 60-80 individuals at any one time on our Intermediate Care pathway in the community following a period of acute/medical intervention. The service will deliver 180 direct care hours per day, 7 days per week, 365 days per year This service will: • Promote faster recovery from illness • Prevent unnecessary acute hospital admissions and premature admissions to long-term care • Support timely discharge from hospital • Maximise independent living. The service focusses on personal care and rehab and reablement interventions, which will be provided to the person to help them rehabilitate, re-able and recover as much as possible from the event that led to their acute inpatient/virtual ward stay (or to prevent a hospital admission) and maximise their independence, delivered in their own home. The optimum average length of stay on the service will be 17 days. A full specification is available on request from the ICB email address provided in this notice. NHS Devon has a requirement for a fully CQC compliant service, with a minimum rating of good, to fully manage provision to support circa 60-80 individuals at any one time on our Intermediate Care pathway in the community following a period of acute/medical intervention. This service will be on a block basis through a set number of hours of delivery and reimbursed at a fixed hourly rate to encompass all costs. Due to operational demand, this service provision will need to remain flexible in response to system needs and may therefore need to be increased against the 60-80 baseline. The service is designed to support people following: • Acute hospital stay (step down) • A bedded Intermediate Care pathway (step-down) • Deterioration in the community to prevent hospital admission (step up) Intermediate Care Pathway 1 personal care, rehab and reablement, will be short-term, time-restricted, supporting a goal-based period of care that calls on a mixture of health and social care assessments and interventions to support people to maximise their potential to live as independently as possible by recovering or continuing to improve skills because of those interventions. The service will operate on a 7-day basis (including bank holidays) between the core operating hours of 7am and 11pm and accepting referrals during this time. The service operates 24/7 'on call' and 'out of hours' cover. This service will include but is not limited to: people living with frailty, mild cognitive impairment, dementia or delirium, palliative and end of life care needs, mental health conditions, learning disabilities, autism, obesity (including bariatric patients), younger adults, and people living in an unsafe environment, experiencing homelessness, or at risk of homelessness. The objectives of the service are: • Enable same day discharge or admission once referral criteria are met • Embed rehab and reablement principles throughout delivery • Deliver personalised, strength based goal planning • Support flow across acute, community, and home settings • Reduce acute length of stay and re admissions The service will ensure oversight from registered therapists and nurses to provide specialist and bespoke interventions and manage complexity, with protocols in place for delegation, accountability and supervision. The service will maximise the use of skilled support workers and other staff and volunteers with direction, advice and oversight from registered therapists and nurses. The provider will work in full collaboration with the Livewell Southwest DTA Team to support the person to achieve their rehab and reablement goals. Referrals into the Home Based Intermediate Care (HBIC) will be made via: - The Integrated Hospital Discharge Team - Livewell Southwest DTA Team - CCRT / UCR - or other agreed system partners as determined by the Commissioner The provider will • Accept referrals 7 days per week including weekends and Bank Holidays • Respond to all referrals within 2 hours (08:00-16:00, with an on-call arrangement to consider urgent referrals, 7 days/week) • Work flexibly to support same day admission or discharge wherever possible. • Daily slot based model to support hospital flow (number of daily slots and any variation to be agreed with commissioner in advance) • Only decline referrals where the person's needs fall outside the scope of this specification • The Provider must not introduce additional access thresholds or eligibility criteria beyond those set out in the specification. Additional information: This service is seen as an essential element in the delivery of rehab and reablement so will need to work collaboratively with other teams across health and social care including (but not limited to): • Livewell Southwest Discharge to Assess (DTA) Team • Acute and Community Discharge Teams • Urgent Community Response / CCRT • GPs and Dis